Frequency, types, severity, preventability and costs of Adverse Drug Reactions at a tertiary care hospital.

INTRODUCTION: Hospital-based adverse drug reaction (ADR) monitoring and reporting studies are conducted to identify, quantify and minimize such risks associated with the use of drugs particularly on long-term basis. Kashmir province of Indian state of Jammu and Kashmir presents a huge market for medicines that runs into millions of rupees. Yet there was no provision to monitor these drugs for their adverse effects prior to this study in any of the leading hospitals of the province. As such the present study, which was first of its kind in the valley, was undertaken to assess the frequency, preventability, category, severity, causality, extension of hospital stay and costs of drug-related adverse effects in Kashmiri patients at a Srinagar-based tertiary care hospital. METHODS: A prospective, observational, cohort study on 5482 patients was undertaken over a 270day period. Adult patients admitted in Internal Medicine in-patient department (IPD), presenting to the Internal Medicine out-patient department (OPD) and those visiting the Accident and Emergency Department of the study hospital were included in the study. Patients belonging to both the sexes were screened and monitored on a daily basis for the occurrence of any ADRs. Definition of ADR given by the World Health Organization (WHO) was used and causality of suspected ADRs was determined using Naranjo's algorithm whereas severity was assessed using modified Hartwig's scale and preventability was determined using Hallas methodology. Costs of ADRs and extension in hospital stay were calculated as per Lagnaou and Nicholas methodology respectively. RESULTS: ADRs accounted for 6.23% of adult Kashmiri patients visiting the tertiary care hospital under study, either for referral or hospitalization, with the majority (81.57%) of these ADRs being preventable; 23.68% of patients had mild ADRs, 69.29% had ADRs of moderate severity, and 7.01% had severe ADRs. Four classes of drugs most frequently suspected in admissions due to ADRs were anti-infective agents (40.92%) including anti-tubercular drugs (13.15%), steroids (14.03%), anti-coagulants (8.77%), and NSAIDs (7.89%). Increasing age and female gender were identified as risk factors. The total cost to the hospital due to hospitalization of patients presenting with ADRs over the 9-month period in the internal medicine IPD was found to be USD 22469 at the time of this study. DISCUSSION/CONCLUSION: The present work is the maiden pharmacovigilance study conducted on Kashmiri patients, especially at a tertiary care teaching hospital that has provided baseline information about the prevalence of ADRs and their distribution among different age groups, genders, organ systems affected, and therapeutic classes of medicines. The data collected will be useful for long term and more extensive ADR monitoring on Kashmiri patients and will also be useful in framing policies toward the rational use of drugs. This study led to the establishment of a full-fledged pharmacovigilance centre and initiation of pharmaceutical care services in the study hospital.

MMSET/WHSC1 enhances DNA damage repair leading to an increase in resistance to chemotherapeutic agents.

MMSET/WHSC1 is a histone methyltransferase (HMT) overexpressed in t(4;14)+ multiple myeloma (MM) patients, believed to be the driving factor in the pathogenesis of this MM subtype. MMSET overexpression in MM leads to an increase in histone 3 lysine 36 dimethylation (H3K36me2), and a decrease in histone 3 lysine 27 trimethylation (H3K27me3), as well as changes in proliferation, gene expression and chromatin accessibility. Prior work linked methylation of histones to the ability of cells to undergo DNA damage repair. In addition, t(4;14)+ patients frequently relapse after regimens that include DNA damage-inducing agents, suggesting that MMSET may play a role in DNA damage repair and response. In U2OS cells, we found that MMSET is required for efficient non-homologous end joining as well as homologous recombination. Loss of MMSET led to loss of expression of several DNA repair proteins, as well as decreased recruitment of DNA repair proteins to sites of DNA double-strand breaks (DSBs). By using genetically matched MM cell lines that had either high (pathological) or low (physiological) expression of MMSET, we found that MMSET-high cells had increased damage at baseline. Upon addition of a DNA-damaging agent, MMSET-high cells repaired DNA damage at an enhanced rate and continued to proliferate, whereas MMSET-low cells accumulated DNA damage and entered cell cycle arrest. In a murine xenograft model using t(4;14)+ KMS11 MM cells harboring an inducible MMSET shRNA, depletion of MMSET enhanced the efficacy of chemotherapy, inhibiting tumor growth and extending survival. These findings help explain the poorer prognosis of t(4;14) MM and further validate MMSET as a potential therapeutic target in MM and other cancers.

FOXP3 is a direct target of miR15a/16 in umbilical cord blood regulatory T cells.

Exact mechanism of action of umbilical cord blood (CB)-derived regulatory T cells (Tregs) in the prevention of GVHD remains unclear. On the basis of selective overexpression of peptidase inhibitor 16 in CB Tregs, we explored the related p53 pathway, which has been shown to negatively regulate miR15a/16 expression. Significantly lower levels of miR15a/16 were observed in CB Tregs when compared with conventional CB T cells (Tcons). In a xenogeneic GVHD mouse model, lower levels of miR15a/16 were also found in Treg recipients, which correlated with a better GVHD score. Forced overexpression of miR15a/16 in CB Tregs led to inhibition of FOXP3 and CTLA4 expression and partial reversal of Treg-mediated suppression in an allogeneic mixed lymphocyte reaction that correlated with the reversal of FOXP3 demethylation in CB Tregs. On the other hand, miR15a/16 knockdown in CB Tcons led to expression of FOXP3 and CTLA4 and suppression of allogeneic lymphocyte proliferation. Using a luciferase-based mutagenesis assay, FOXP3 was determined to be a direct target of miR15a and miR16. We propose that miR15a/16 has an important role in mediating the suppressive function of CB Tregs and these microRNAs may have a 'toggle-switch' function in Treg/Tcon plasticity.

HINCUTs in cancer: hypoxia-induced noncoding ultraconserved transcripts.

Recent data have linked hypoxia, a classic feature of the tumor microenvironment, to the function of specific microRNAs (miRNAs); however, whether hypoxia affects other types of noncoding transcripts is currently unknown. Starting from a genome-wide expression profiling, we demonstrate for the first time a functional link between oxygen deprivation and the modulation of long noncoding transcripts from ultraconserved regions, termed transcribed-ultraconserved regions (T-UCRs). Interestingly, several hypoxia-upregulated T-UCRs, henceforth named 'hypoxia-induced noncoding ultraconserved transcripts' (HINCUTs), are also overexpressed in clinical samples from colon cancer patients. We show that these T-UCRs are predominantly nuclear and that the hypoxia-inducible factor (HIF) is at least partly responsible for the induction of several members of this group. One specific HINCUT, uc.475 (or HINCUT-1) is part of a retained intron of the host protein-coding gene, O-linked N-acetylglucosamine transferase, which is overexpressed in epithelial cancer types. Consistent with the hypothesis that T-UCRs have important function in tumor formation, HINCUT-1 supports cell proliferation specifically under hypoxic conditions and may be critical for optimal O-GlcNAcylation of proteins when oxygen tension is limiting. Our data gives a first glimpse of a novel functional hypoxic network comprising protein-coding transcripts and noncoding RNAs (ncRNAs) from the T-UCRs category.

Anti-anxiety activity of Stachys tibetica Vatke.

AIM: S. tibetica Vatke is a herb distributed in the tropical and subtropical regions of the world, including Tibet, China, and India. In India it is found in the cold desert regions of Kargil, Ladakh Valley, and in the mountains of Himachal Pradesh. The traditional practitioners in the Kargil and Ladakh use the natural medicine Stachys tibetica for the treatment of various mental disorders and phobias. The present study is aimed at evaluating the anxiolytic effects of the methanolic extract of the root, stem, leaf, and whole plant material of Stachys tibetica Vatke in rats. METHODS: Powdered materials (1 kg) of each plant part were subjected to extraction in a Soxhlet apparatus with methanol (95%); to yield 12.8%, 8.3%, 17.2%, and 19.6% W/W extractives, respectively. Extracts were evaluated for their anxiolytic effects using the elevated plus maze (EPM) test in rats. RESULTS: In the present study, it was found that the methanolic extracts (200 and 400 mg·kg(-1)) of the root, stem, leaf and whole plant of Stachys tibetica Vatke and diazepam (DZ) increased the time spent and the number of entries in the open arm significantly (**P < 0.01), while they decreased the time spent and the number of entries in the closed arm. At the same time, all of the extracts and DZ decreased the time spent at the center of the maze (latency), along with closed arm returns. The head dip counts increased significantly in the rats treated with DZ, SMR400, SML400 and SMW400 in the open arm of EPM, which was a sign of reduction anxiety. The DZ and SMW did not show the fecal bolus, while other groups had reduced fecal bolus (**P < 0.01) as compared to control. These allied parameters helped to assess the anxiolytic potential of Stachys tibetica Vatke. Whole plant and leaf materials have shown the maximum activity, the root intermediate while the stem had the least anxiolytic activity (*P < 0.05, **P < 0.01) in EPM. CONCLUSION: The results strongly justify the use of this plant for the treatment of anxiety. Further studies are in progress in this laboratory to isolate and identify the components responsible for the anxiolytic activity and the mechanism of action involved.

Coumarins from Angelica archangelica Linn. and their effects on anxiety-like behavior.

UNLABELLED: TRADITIONAL RELEVANCE: Angelica archangelica Linn. (Apiaceae) is an herb distributed in tropical and subtropical regions of the world. Both in Chinese and Indian system of medicine, it is used for nervous disorders including anxiety, anorexia, migraine and other cerebral diseases. AIM OF STUDY: To evaluate the anxiolytic potential of non polar coumarins isolated from A. archangelica Linn. METHODS AND RESULTS: A. archangelica Linn. (1 kg) was subjected to extraction in a soxhlet apparatus with petroleum ether (40-60 °C), yield 6.9% w/w. The extract of petroleum ether produced a yellow colored precipitate (YP) which was evaluated for anxiolytic like effect using EPM test and was found significant (**P<0.01) in doses of 5 and 10 mg/kg, po. The precipitate was shown to be a mixture of seven constituents in HPTLC and six on the TLC plate which were further subjected to separation by preparative TLC. Non polar coumarins were isolated namely imperatorin (IM) and isoimperatorin (IIM). YP, IM, IIM were tested for anxiolytic like effects in a dose of 5mg/kg, po along with DZ (1mg/kg, po) using EPM, Light & dark arena and hole board models in rats. All the test drugs were found to have significant (*P<0.05, **P<0.01) activity. IM and IIM have the potential to reduce anxiety but yellow precipitate showed the most promising activity as compared to isolated coumarins. This effect may be due to the synergistic action of all compounds present in the YP or by multiple mechanism of action. The test drugs may have the potential for different receptors. CONCLUSION: The mixture of coumarins isolated from A. archangelica and its constituents imperatorin and isoimperatorin have the potential to reduce anxiety but it is the mixture which have more significant activity as compared to its individual components.

The histone methyltransferase MMSET/WHSC1 activates TWIST1 to promote an epithelial-mesenchymal transition and invasive properties of prostate cancer.

Epigenetic deregulation of gene expression has a role in the initiation and progression of prostate cancer (PCa). The histone methyltransferase MMSET/WHSC1 (Multiple Myeloma SET domain) is overexpressed in a number of metastatic tumors, but its mechanism of action has not been defined. In this work, we found that PCa cell lines expressed significantly higher levels of MMSET compared with immortalized, non-transformed prostate cells. Knockdown experiments showed that, in metastatic PCa cell lines, dimethylation of lysine 36 and trimethylation of lysine 27 on histone H3 (H3K36me2 and H3K27me3, respectively) depended on MMSET expression, whereas depletion of MMSET in benign prostatic cells did not affect chromatin modifications. Knockdown of MMSET in DU145 and PC-3 tumor cells decreased cell proliferation, colony formation in soft agar and strikingly diminished cell migration and invasion. Conversely, overexpression of MMSET in immortalized, non-transformed RWPE-1 cells promoted cell migration and invasion, accompanied by an epithelial-mesenchymal transition (EMT). Among a panel of EMT-promoting genes analyzed, TWIST1 expression was strongly activated in response to MMSET. Chromatin immunoprecipitation analysis demonstrated that MMSET binds to the TWIST1 locus and leads to an increase in H3K36me2, suggesting a direct role of MMSET in the regulation of this gene. Depletion of TWIST1 in MMSET-overexpressing RWPE-1 cells blocked cell invasion and EMT, indicating that TWIST1 was a critical target of MMSET, responsible for the acquisition of an invasive phenotype. Collectively, these data suggest that MMSET has a role in PCa pathogenesis and progression through epigenetic regulation of metastasis-related genes.

Anti-anxiety activity of successive extracts of Angelica archangelica Linn. on the elevated T-maze and forced swimming tests in rats.

OBJECTIVE: Angelica archangelica Linn. is widely used in food and liquor preparations and also in Kashmiri folk medicine to reduce anxiety. We evaluated the anxiolytic effect of successive extracts of A. archangelica linn. (SAE) on rats tested in the elevated T-maze test (an animal model of generalized anxiety) at doses that exhibit antidepressant-like activity in humans. METHODS: A. archangelica (1 kg) was subjected to successive extraction in a soxhlet apparatus with solvents [petroleum ether (40-60 degrees C), chloroform, ethyl acetate, methanol and decoction with water] in order of increasing polarity (yield: 6.9%, 7.3%, 5.1%, 11.88% and 8.2% w/w, respectively). SAE were evaluated for anxiolytic effects using the elevated T-maze and forced swimming tests in rats. RESULTS: Oral dosing of diazepam (1 mg/kg) and extracts (50, 100 and 200 mg/kg) clearly showed an anxiolytic-like profile in the elevated T-maze test: it increased one-way escape and decreased inhibitory avoidance on the first, third and seventh day. In the forced swimming test, imipramine and SAE showed antidepressant- and anxiolytic-like effects as reflected by increased climbing time, swimming time and decreased immobility time on the first, third and seventh day. Aqueous and methanol extracts showed the most, petroleum ether (40-60 degrees C) and chloroform intermediate, and ethyl acetate the least anxiolytic activity (*P<0.05, **P<0.01, ***P< 0.001) in both models. CONCLUSIONS: These results suggest the anti-anxiety activity of various extracts of A. archangelica and strongly justify its use in traditional Indian medicine for the treatment of anxiety.

Hemodialysis Utilization in a Single in-Center Dialysis Unit, in the Kingdom of Saudi Arabia.

This study was performed to find out the trends in the demand for regular maintenance hemodialysis (HD) and to assess the utilization with reference to selected variables. In a retrospective cohort study, data from a single in-center HD unit of a secondary care hospital located in the south-western part of the Kingdom of Saudi Arabia, were analyzed. Cases of end-stage renal failure (ESRF) registered for regular maintenance HD from the commencement of the HD services in this center (1987 to 2000) formed the subjects of this study. Utilization of the in-center HD was assessed by annual growth rate, death rate, renal transplantation rate and utilization rate. Simple descriptive statistics were used for data analysis. During the study period, 393 cases were registered for regular maintenance HD. There were 183 males (46.6%) and 210 females (53.4%). The mean and median ages of the patients at the initiation of HD were 40.7 and 35 years respectively. Saudis constituted 75.1%(295) over the years studied. The mean annual growth rate, death rate, renal transplantation rate and utilization rate were 7.44, 9.3, 4.33 and 139.57% respectively. Demand for maintenance HD was more from young individuals, which is similar to the national figures. Annual growth rate of those requiring HD was far higher than population growth of this region during the period of study caused primarily by an increased number of new entries coupled with low death and transplantation rates. We conclude that HD utilization studies help to unearth the problems, understand the needs, communicate with the authorities (with facts and figures), find out solutions, and create a network between providers and consumers.

Detection of autonomic nervous dysfunction by SL manoeuvre.

We have evaluated the immediate heart rate response to standing and lying and in 100 Diabetic subjects aged 43 +/- 10 years who underwent five other cardiovascular autonomic tests. Using a specially devised scoring system the patients were divided into three groups: a) 58 subjects without autonomic neuropathy, b) 15 borderliners, c) 27 with autonomic neuropathy. The results were compared with 50, sex and age matched controls. We studied SL1 = ratio between R-R mean before lying and R-R maximum between the 20th to 25th beat and R-R minimum over the first 5 beats after lying. In controls SL1 was 1.35 +/- 0.18 and SL2 was 1.52 +/- 0.23. In diabetic subjects without autonomic neuropathy SL1 was 1.20 +/- 0.86 (p < 0.01), SL2 1.50 +/- 0.02 (p < 0.001). In the group with autonomic neuropathy SL1 was 1.04 +/- 0.02 (p < 0.001) and SL2 was 1.20 +/- 0.09 (p < 0.001). We propose that the lowest normal and highest abnormal limits of SL1 are 1.12 and 1.08 respectively and that normal and highest abnormal limits of SL2 are 1.23 and 1.18 respectively. We suggest the use of SL1 as a pure parasympathetic test and SL2 as a mixed but predominantly sympathetic test in the diagnosis of autonomic neuropathy.

Multiple drug resistant typhoid fever outbreak in Kashmir Valley.

We report the first ever report of multiple drug resistant salmonella typhi epidemic from Asia. The outbreak started in April 1988 and virtually ended by June 1988. The outbreak occurred in Baramullah town of Kashmir valley. In an epidemiological survey 230 cases were diagnosed as enteric fever. 46 cases (20%) were culture positive. A very rare multiple drug resistant strain of S. typhi was identified as phage type biotype II untypeable (UVS2). The strain was sensitive to Norfloxacin. This outbreak of S. typhi has many similarities with Mexico epidemic. Ingestion of contaminated water seems to be the possible cause for the outbreak.

Neuropsychiatric manifestations of typhoid fever.

Various neuropsychiatric syndromes in typhoid fever were seen in nine patients of multiple drug resistant (both in vitro and in vivo) Salmonella typhi infection of a total of 270 suspected cases in the last two years. All but one patient received oral norfloxacin (400 mg 12 hourly) for two weeks with complete recovery, while the other patient died. Bacteremia and toxemia seem to be the only common factor responsible for neuropsychiatric complications.